MENTAL HEALTH, SUBSTANCE ABUSE, AUTISM AND BEHAVIORAL HEALTH SERVICES SUMMARY PLAN DESCRIPTION

Transcription

1 MENTAL HEALTH, SUBSTANCE ABUSE, AUTISM AND BEHAVIORAL HEALTH SERVICES SUMMARY PLAN DESCRIPTION prepared exclusively for the UNIVERSITY OF PENNSYLVANIA ("UPenn") July 1, 2016

2 TABLE OF CONTENTS I. INTRODUCTION TO THE UNIVERSITY OF PENNSYLVANIA BEHAVIORAL HEALTH BENEFITS page 1 A. About Penn Behavioral Health Corporate Services B. Eligibility II. HOW THE BENEFITSWORKS page 4 A. In-Network Provider and Facility B. Out-of-Network Provider and Facility C. Single Case Agreement III. COVERED SERVICES page 5 A. Routine Services B. Non-routine Services 1. Non-routine Mental Health Services 2. Non-routine substance Abuse Services 3. Crisis Evaluations and Emergency Admissions 4. Specialized Services a. Inpatient and/or Ourtpatient Electroconvulsive Thearpy (ECT) b. Psychological Testing c. Transcranial Magnetic Stimulation (TMS) d. Autism Spectrum Disorder (ADS) Treatment IV. TREATMENT GUIDELINES page 8 A. Clinical Assessment and Treatment Planning B. Reassessment C. Discharge Planning and Coordination of Care V. UTILIZATION REVIEW PROCESS page 10 A. Preauthorization B. Concurrent Reviews C. Retrospective Reviews D. Verbal Preauthorization E. Written Notice of Authorization of Coverage Determination F. Written Notice of Denial of Coverage Determination G. Written Notice of Denial of Payment VI. NON-COVERED SERVICES page 11 VII. COORDINATION OF BENEFITS page 14 VIII. AUDITS page 15 IX. PAYMENTS page 15 A. Filing Claims B. Types of Claims 1. Urgent Care Claims 2. Pre-Service Claims 3. Concurrent Care Claims 4. Post-Service Claims C. How to File a Claim X. APPEALS OF ADVERSE DETERMINATION page 18 A. First Level Internal Appeal Timeline B. Content of First Level Internal Appeal Decision Notification C. Second Level External Appeal Timeline D. Content of Second Level External Appeal Decision Notification E. Calculating Response Time F. Failure to Follow Appeal Timeline

3 G. External Review Determination H. Benefit Claims Litigation XI. APPOINTMENT OF AUTHORIZATION REPRESENTATIVE page 22 XII. PHYSICIAL EXAMINATIONS page 22 XIII. COMPLAINT PROCESS page 22 XIV. DEFINITIONS page 23

4 I. INTRODUCTION TO THE UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM BEHAVIORAL HEALTH BENEFITS This Summary Plan Description ("SPD") summarizes the main terms of the Behavioral Health Benefits provided to eligible employees of the University of Pennsylvania Health System ("UPENN") and their dependents. Behavioral Health Benefits are administered by Penn Behavioral Health Corporate Services ("PBHCS"). Behavioral Health Benefits are offered pursuant to a self-funded, Administrative Services Only ("ASO") arrangement, under which UPENN assumes responsibility for the payment of benefits while receiving administrative services from PBHCS. Administrative services include the preparation of an administration manual, communication with employees, determination and payment of benefits, preparation of government reports, preparation of summary plan descriptions, and accounting. UPENN is liable for the financial (claims and related expenses) and legal aspects of Behavioral Health Benefits. PBHCS will provide coverage for various Medically Necessary levels of care and without the need of referrals from a Primary care physician. Please use this booklet as a reference guide to familiarize yourself with all aspects of your Behavioral Health Benefits. Important: If you are facing an emergency and must go to an emergency room, you do not need a referral from PBHCS. However, you (or your representative or your physician) must call PBHCS within 48 hours after Emergency care is given. If this is not reasonably possible, the call must be made as soon as reasonably possible. A. About Penn Behavioral Health Corporate Services PBHCS provides behavioral health services uniquely tailored to all eligible employees and their dependents. PBHCS intends to promote wellness and prevention, and assist Members with accessing treatment that supports meaningful, enduring and positive change. PBHCS is proud to offer Service Excellence with Integrity by showing commitment to the ones it serves, compassionate listening, collaboration and guidance navigating the system, and building trust with Members and its broad network of professionals who service them. Care Managers are Licensed Master Level Clinicians available during business hours Monday through Friday from 8:30 a.m. to 5:00 p.m. Eastern Standard Time. Care Managers assist with eligibility and benefits inquiries, referrals to a wide range of services, providers and facilities, guidance accessing treatment, and authorization to non-routine services. Additionally, an on-call clinician is available, twenty-four hours a day, seven days a week including holidays and weekends, to facilitate urgent and emergent situations such as inpatient admissions. B. Eligibility If you elect Medical Plan coverage under the UPENN Medical Plan, you are eligible to receive the Behavioral Health Benefits described in this SPD. More specifically, Behavioral Health Benefits are available to eligible employees and their eligible dependents, retirees and COBRA members ("Covered Persons") who have properly enrolled in one of the following options under the UPENN Medical Plan: - UPENN PENNCARE/Personal Choice PPO Plan - UPENN Personal Choice PennCare PPO Behavioral Health Benefits Plan for Retiree pre UPENN Point of Service AETNA Choice POS II Plan - UPENN AETNA Choice POS II Behavioral Health Benefits Plan for Retirees per-65 - UPENN AETNA Affordable Care Act Behavioral Health Benefits Plan 1

5 To inquire about eligibility and to review how your Behavioral Health Benefits work, call Penn Behavioral Health Corporate Services (PBHCS) at , you may also visit PBHCS website at The benefit plan summary for FY2017 (Plan Year July 1, 2016 June 30, 2017) is as follows: 2

6 University of Pennsylvania Aetna Choice POS II Behavioral Health Benefits Plan for Retirees pre- 65 (CY2016 Effective 1/1/16) Benefit In-Network Out-of-Network Overall Annual Deductibles 1 Overall Annual Out of Pocket Maximum 1, 2 Includes deductible, co-insurance and co-payments $ Individual $ Family $1, Individual $3, Family $ Individual $2, Family $2, Individual $7, Family MENTAL HEALTH ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Acute Inpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Partial Hospitalization 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Intensive Outpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $30.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room $ co-pay (waived if admitted) CHEMICAL DEPENDENCY ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Detoxification 3 and Rehabilitation 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Partial Hospitalization 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Intensive Outpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $30.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room SPECIALIZED TREATMENT $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION Psychological Testing 3, ECT 3, TMS 3 100% 40% 4 coinsurance after deductible Autism Outpatient Services 3 including Applied Behavioral Analysis (ABA) and selected Behavioral Health Rehabilitative Services (BHRS) Treatment Delivered by PBHCS Network Providers 100% Covered 1 Annual deductible and out-of-pocket maximum shared between mental health, chemical dependency, and medical benefits 2 It is the responsibility of the member to demonstrate that the annual out-of-pocket maximum (medical, mental health and chemical dependency) has been reached for reimbursement 3 Preauthorization is required 4 It is important to note that all percentages for services represent the plan allowance and not the provider's actual charge 3

7 University of Pennsylvania Aetna Choice POS II Behavioral Health Benefits Plan (FY2017 Effective 7/1/16) Benefit In-Network Out-of-Network Overall Annual Deductibles 1 $ Individual $ Family $ Individual $2, Family Overall Annual Out of Pocket Maximum 1, 2 Includes deductible, co-insurance and co-payments MENTAL HEALTH $1, Individual $3, Family $2, Individual $7, Family ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Acute Inpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Partial Hospitalization 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Intensive Outpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $30.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room CHEMICAL DEPENDENCY $ co-pay (waived if admitted) ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Detoxification 3 and Rehabilitation 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Partial Hospitalization 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Intensive Outpatient 3 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $30.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room SPECIALIZED TREATMENT $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION Psychological Testing 3, ECT 3, TMS 3 100% 40% 4 coinsurance after deductible Autism Outpatient Services 3 including Applied Behavioral Analysis (ABA) and selected Behavioral Health Rehabilitative Services (BHRS) Treatment Delivered by PBHCS Network Providers 100% Covered 1 Annual deductible and out-of-pocket maximum shared between mental health, chemical dependency, and medical benefits 2 It is the responsibility of the member to demonstrate that the annual out-of-pocket maximum (medical, mental health and chemical dependency) has been reached for reimbursement 3 Preauthorization is required 4 It is important to note that all percentages for services represent the plan allowance and not the provider's actual charge 4

8 University of Pennsylvania Personal Choice PennCare PPO Behavioral Health Benefits Plan for Retirees pre-65 (CY2016 Effective 1/1/16) Benefit Overall Annual Deductibles 1 Overall Annual Out of Pocket Maximum 1, 2 Includes deductible, co-insurance and co-payments Acute Inpatient 3 MENTAL HEALTH Partial Hospitalization 3 Intensive Outpatient 3 In-Network (PBHCS Preferred) $ Individual $ Family $1, Individual $3, Family In-Network (PBHCS Regional) $ Individual $ Family $2, Individual $7, Family Out-of-Network $ Individual $1, Family $3, Individual $10, Family ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible 40% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $20.00 co-pay per session $25.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room CHEMICAL DEPENDENCY Detoxification 3 and Rehabilitation 3 Partial Hospitalization 3 Intensive Outpatient 3 $ co-pay (waived if admitted) ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40% 4 coinsurance after deductible 40% 4 coinsurance after deductible 40% 4 coinsurance after deductible Outpatient Office Visit $20.00 co-pay per session $25.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room SPECIALIZED TREATMENT $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION Psychological Testing 3, ECT 3, TMS 3 100% 20% 4 coinsurance 40% 4 coinsurance after deductible Autism Outpatient Services 3 including Applied Behavioral Analysis (ABA) and selected Behavioral Health Rehabilitative Services (BHRS) Treatment Delivered by PBHCS Network Providers 100%Covered 1 Annual deductible and out-of-pocket maximum shared between mental health, chemical dependency, and medical benefits 2 It is the responsibility of the member to demonstrate that the annual out-of-pocket maximum (medical, mental health and chemical dependency) has been reached for reimbursement 3 Preauthorization is required 4 It is important to note that all percentages for services represent the plan allowance and not the provider's actual charge 4

9 University of Pennsylvania Aetna Affordable Care Act Behavioral Health Benefits Plan (FY2017 Effective 7/1/16) Benefit In-Network Out-of-Network Overall Annual Deductibles 1 Overall Annual Out of Pocket Maximum 1, 2 Includes deductible, co-insurance and co-payments MENTAL HEALTH $ Individual $1, Family $4, Individual $9, Family $2, Individual $4, Family $9, $19, ALL SERVICES REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Acute Inpatient 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Partial Hospitalization 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Intensive Outpatient 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Outpatient Office Visit $40.00 co-pay per session 50% 4 coinsurance after deductible Emergency Room CHEMICAL DEPENDENCY $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Detoxification 3 and Rehabilitation 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Partial Hospitalization 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Intensive Outpatient 3 30% 4 coinsurance after deductible 50% 4 coinsurance after deductible Outpatient Office Visit $40.00 co-pay per session 50% 4 coinsurance after deductible Emergency Room SPECIALIZED TREATMENT $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION Psychological Testing 3, ECT 3, TMS 3 100% 50% 4 coinsurance after deductible Autism Outpatient Services 3 including Applied Behavioral Analysis (ABA) and selected Treatment Delivered by PBHCS Network Providers 100% Covered 1 Annual deductible and out-of-pocket maximum shared between mental health, chemical dependency, and medical benefits 2 It is the responsibility of the member to demonstrate that the annual out-of-pocket maximum (medical, mental health and chemical dependency) has been reached for reimbursement 3 Preauthorization is required 4 It is important to note that all percentages for services represent the plan allowance and not the provider's actual charge 5

10 University of Pennsylvania Personal Choice PennCare PPO Behavioral Health Benefits Plan (FY2017 Effective 7/1/16) Benefit Overall Annual Deductibles 1 Overall Annual Out of Pocket Maximum 1, 2 Includes deductible, co-insurance and copayments MENTAL HEALTH In-Network (PBHCS Preferred) $ Individual $ Family $1, Individual $3, Family In-Network (PBHCS Regional) $ Individual $1, Family $2, Individual $7, Family Out-of-Network $ Individual $1, Family $3, Individual $10, Family ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Acute Inpatient 3 Partial Hospitalization 3 Intensive Outpatient 3 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible Outpatient Office Visit $20.00 co-pay per session $25.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room $ co-pay (waived if admitted) CHEMICAL DEPENDENCY ALL SERVICE REQUIRE PREAUTHORIZATION EXCEPT FOR OUTPATIENT OFFICE VISITS Detoxification 3 and Rehabilitation 3 10% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible Partial Hospitalization 3 Intensive Outpatient 3 10% 4 coinsurance after deductible 10% 4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible 20% 4 coinsurance after deductible Prof Services: 20% 4 coinsurance after deductible 40%4 coinsurance after deductible Outpatient Office Visit $20.00 co-pay per session $25.00 co-pay per session 40% 4 coinsurance after deductible Emergency Room SPECIALIZED TREATMENT $ co-pay (waived if admitted) ALL SERVICES REQUIRE PREAUTHORIZATION Psychological Testing 3, ECT 3, TMS 3 100% 20% 4 coinsurance 40% 4 coinsurance after deductible Autism Outpatient Services 3 including Applied Behavioral Analysis (ABA) and selected Behavioral Health Rehabilitative Services (BHRS) Treatment Delivered by PBHCS Network Providers 100% Covered 1 Annual deductible and out-of-pocket maximum shared between mental health, chemical dependency, and medical benefits 2 It is the responsibility of the member to demonstrate that the annual out-of-pocket maximum (medical, mental health and chemical dependency) has been reached for reimbursement 3 Preauthorization is required 4 It is important to note that all percentages for services represent the plan allowance and not the provider's actual charge 6

11 II. HOW THE BENEFITS WORK UPENN has entered into an agreement to allow PBHCS to manage and provide Behavioral Health Benefits through a broad network of licensed providers and hospitals affiliated with Penn Medicine or contracted third parties that are part of the PBHCS Network known as In-Network Providers. The benefit period begins July 1 of each year and Covered Persons have the option of selecting either In- Network Providers or Out-of-Network Providers to access their Behavioral Health Benefits. It is the Member's responsibility to verify the network status of Providers and Facilities before receiving treatment and to inquire with PBHCS about the need for Preauthorization before receiving treatment. A. In-Network Provider and Facility PBHCS In-Network Providers work directly with PBHCS to provide high quality and cost efficient services to UPENN Members. Utilizing In-Network Providers for your Behavioral Health needs allows you to lower your out-of-pocket costs and eliminates the needs to submit Out-of Network Claims forms. Note that some Covered Services still require Preauthorization. B. Out-of-Network Provider and Facility Out-of-Network Providers do not have a contract with PBHCS and, therefore, quality of cost efficient services cannot be monitored. Utilizing Out-of-Network Providers for your Behavioral Health Benefits will considerably increase your out-of-pocket costs and necessitate completion and submission of Out-of Network Claims and supporting documents for reimbursement of Covered Services some of which may need Preauthorization. C. Single Case Agreement Under a Single Case Agreement, ( SCA ) PBHCS may allow exceptions to the otherwise-applicable treatment of a provider as an Out-of-Network Provider based on (1) special needs of the Covered Person s condition, (2) lack of availability of In-Network Provider and/or Facility to treat the Covered Person, and (3) the geographical location of residence of the Covered Person at the time of treatment. A SCA is used for non-routine services in an effort to enter into a one-time agreement with an Out-of- Network Facility to deliver treatment and/or services as an In-Network Provider to the Member in a Facility based setting including: - Inpatient Mental Health and/or Substance Abuse, and/or - Therapy while Inpatient, and/or - Medication Management while Inpatient, and/or - Psychological Testing while Inpatient, and/or - Inpatient and Outpatient Electric Convulsive Therapy (ECT), and/or - Autism Spectrum Disorder (ASD) treatment Additionally, a SCA is used in an effort to enter into a one-time agreement of one year with an Out-of- Network Provider to deliver treatment and/or services as an In-Network Provider to the Member in an Outpatient Office Setting including: - Outpatient Therapy, and/or - Outpatient Medication Management, and/or - Psychological Testing, and/or - Transcranial Magnetic Stimulation (TMS) 7

12 Out-of-Network Facilities and Providers may not qualify and/or agree to the requirements of a SCA. The Member may still decide to enter under the care of the Out-of Network Provider/Facility. In this instance, the Member may be eligible to receive reimbursement as per the Out-of-Network Benefits rate schedule when the given Provider/Facility is qualified. All Facilities must be licensed by the state and accredited by The Joint Commission or CARF; Providers must be licensed in the state in which they practice and deliver services. To verify that a Provider or Facility is In-Network with PBHCS call to speak to a Care Manager who can also assist with submitting a SCA when appropriate. III. COVERED SERVICES Covered Services are included in the Behavioral Health Benefit and delivered by PBHCS Network Providers and Facilities contracted to ensure appropriate, time-effective clinical treatment in a manner that is consistent with professional and ethical standards. National certification and state licensing boards, and applicable law and/or regulations set standards for the performance of services regardless of a Member's benefit plan or terms of coverage. A. Routine Services Routine Behavioral Health Services do not require a Preauthorization and include: - Individual and Group Outpatient Therapy - Medication Management by a Psychiatrist or Registered Nurse Practitioner B. Non-routine Services Preauthorization must be obtained from PBHCS for all non-routine Mental Health ("MH") services within 24 hours from admission or sooner in order to assure Medical Necessity and benefit coverage of the proposed treatment. If not reasonably possible, PBHCS must be contacted by the Facility and if appropriate, PBHCS will retroactively authorize coverage for the MH/SA Inpatient services covered by the benefit plan. Non-routine Behavioral Health Services include all treatment and services that require preauthorization including: 1. Non-routine Mental Health Services - Inpatient Mental Health - Residential Treatment - Partial Hospitalization - Intensive Outpatient Program 2. Non-routine Substance Abuse Services - Inpatient Detoxification - Inpatient Rehabilitation - Residential Rehabilitation - Partial Hospitalization - Intensive Outpatient Program Preauthorization for the above-listed non-routine covered services is obtained through a telephone contact between the Facility and a PBHCS Care Manager. 3. Crisis Evaluations and Emergency Admissions Circumstances that warrant an emergency admission are those in which there is a clear and immediate risk to the safety of the Member or another person as a direct result of mental illness or substance use disorder. 8

13 A Medically Necessary admission following stabilization in an emergency room requires authorization prior to the admission to a facility. Preauthorization must be obtained by crisis centers within 48 hours of providing Emergency Care by calling a PBHCS Care Manager. If not reasonably possible, PBHCS must be contacted by the admitting facility within 24 hours of admission. If appropriate, PBHCS will retroactively authorize coverage for the emergency services covered by the benefit plan. Depending on the specific circumstances of each individual case, PBHCS reserves the right to deny coverage for all or part of an admission. All requests for retrospective reviews must be received by PBHCS within 180 calendar days of the date the services were provided to the Member, unless applicable law mandates otherwise. All requests for Non-routine services are processed by Care Managers and authorizations of coverage is based upon the latest version of InterQual by McKesson, organizational clinical guidelines and sound clinical judgment of the clinician processing the request. 4. Specialized Services Preauthorization must be obtained from PBHCS for all specialized services in order to assure Medical Necessity and benefit coverage of the proposed treatment. PBHCS has established specific administrative and coverage criteria for delivery of specialized services considered only after completion of a face-toface clinical assessment. Preauthorization requests for specialized services can be initiated through telephone contact between the Member or Provider/Facility and a PBHCS Care Manager. In addition, the treating Provider must submit the appropriate clinical form with clear clinical documentation no less than 15 business days before rendering services. All requests are carefully evaluated for Medical Necessity and reviewed by the Care Manager and Physician Advisor and/or Executive Medical Director prior to generating authorizations for: a. Inpatient and/or Outpatient Electroconvulsive Therapy (ECT) ECT can be administered while a Member is hospitalized and can continue after discharge at the outpatient level of care. The process is initiated by completing the PBHCS ECT Initial Treatment request. The referring Provider and/or the Provider administering treatment shall complete the form and submit it to PBHCS for approval. The request is reviewed by a psychiatrist. The approval or denial of the request is communicated to the Provider via a phone call and a letter. If approved, authorization is generated for a portion of the treatment. The Provider administering ECT will then provide clinical updates to obtain ongoing required authorizations during the entire treatment. This process is valid for both In-Network and Out-of-Network Providers. b. Psychological Testing The process is initiated by completing the PBHCS Psychological Testing request form. The referring Provider and/or the Provider administering the testing shall complete the form and submit it to PBHCS for approval. The request is reviewed by a psychiatrist. The approval or denial of the request is communicated to the provider and Member via a phone call and a letter. This process is valid for both In-Network and Out-of-Network Providers. c. Transcranial Magnetic Stimulation (TMS) The process is initiated by completing the PBHCS TMS Initial Treatment request form. The referring Provider and/or the Provider administering treatment shall complete the form and submit it to PBHCS for approval. The request is reviewed by a psychiatrist. The approval or denial of the request is communicated to the Provider and Member via a phone call and a letter. If approved, 9

14 authorization is generated for a portion of the treatment. The Provider administering TMS will then submit a Midpoint Treatment Verification form to obtain authorization for the second portion of the treatment. This process is valid for both In-Network and Out-of-Network Providers. d. Autism Spectrum Disorder (ASD) Treatment PBHCS manages the Autism benefit for members enrolled in the Personal Coice PennCare PPO, Atena POS II and Aetna ACA Benefits Plans. Eligible individuals up to age 21 must have a primary diagnosis of Autism. Autism services are continuing and ongoing. The process is initiated with Diagnostic Testing which is pre-authorized by PBHCS. Once diagnosed, the child is assessed by the Penn Medicine Autism Clinic and a Treatment Plan is developed. The Treatment Plan must also be approved by PBHCS. Once the Treatment Plan is implemented, the child s progress is continually monitored by PBHCS. Members must be evaluated at the Penn Medicine Autism Clinic in order to access the Autism Benefit coverage. The Penn Medicine Autism Clinic: 1. Can complete the Comprehensive Diagnostic Evaluation including testing prior to the Comprehensive Assessment and Treatment Plan Formulation; 2. MUST complete a Comprehensive Assessment and Treatment Plan Formulation for all UPENN Members; 3. Creates and submits PBHCS Initial Treatment Plan Form and Initial Services Request Form to PBHCS for review; 4. The PBHCS Initial Treatment Plan Form and Initial Services Request Form include recommendations for: - The Mental Health Assessment (H0031) to be completed by the identified PBHCS Network Provider, and - Selected interventions and identified treatment goals to be delivered by the identified PBHCS Network Provider. The PBHCS Clinical Care Management Team: 1. Processes the PBHCS Initial Treatment Plan Form and Initial Services Request Form prior to the Provider rendering any services to the Member; 2. Provides a copy of the PBHCS Initial Treatment Plan Form and Initial Services Request Form to the identified Provider; and 3. Provides authorizations for the Mental Health Assessment (H0031) and recommended treatment services and the Provider may then deliver treatment. The identified PBHCS network provider: 1. Implements recommended interventions and identified goals recorded in PBHCS Initial Treatment Plan Form; and 2. Can create additional goals as appropriate following the MH Assessment (H0031). Treatment delivered by PCHCS Network Providers is 100% covered. For a full explanation and assistance with navigating your ASD benefit, visit PBHCS website at or call PBHCS at to speak to a Care Manager 10

15 It is critical for both In-Network and Out-of-Network Providers to obtain preauthorization from PBHCS to ensure the services requested are deemed Medically Necessary and appropriate and meet criteria and requirements set forth by PBHCS. Authorizations are specific to the clinician/facility and payment for any specific CPT and/or HCPCS code is subject to ongoing medical necessity review. Failure to obtain or otherwise follow the required administrative procedures for preauthorization, PBHCS may, in accordance with applicable law, apply a reduction of payment to the Network Provider. Payment reductions for failure to obtain preauthorization are solely the Network Provider's liability. Under no circumstances should a Member be billed for services provided by a Provider/Facility with the exception of any applicable deductible, co-payment, and co-insurance. For all clinical procedural questions, call PBHCS at Coverage is subject to all terms, policies and procedures outlined in this booklet. Not all expenses are covered under the plan. Exclusions and limitations apply to certain services. The lack of a specific exclusion does not imply that the service is covered. IV. TREATMENT GUIDELINES Treatment Guidelines are a set of objective and evidence-based behavioral health guidelines used to standardize coverage determinations, promote evidence-based practices, optimize clinical outcomes, and support Members' recovery and consistency in the authorization of benefits. Treatment Guidelines are used to make Medical Necessity determinations and serve as guidance when providing referral assistance. Services are Medically Necessary when they are provided for the purpose of preventing, evaluating, diagnosing or treating a mental illness or substance use disorder, or its symptoms. Medically Necessary standards are based on credible scientific evidence published in peer-reviewed medical literature relying primarily on controlled clinical trials. PBHCS Treatment Guidelines include InterQual Criteria by McKesson Health Solutions to support the determination of facility based treatments and supplement and not replace sound clinical judgment of the care management team. The InterQual clinical criteria by McKesson Health Solutions are revised from time to time and customized for PBHCS to better assist the needs of the UPENN Covered Persons. A copy of the InterQual clinical criteria by McKesson Health Solutions is available on the PBHCS' website or by calling ; printed copies are provided upon request. While the Treatment Guidelines reflects PBHCS understanding of current best practices in care, it does not constitute medical advice. PBHCS reserves the right, in its sole discretion, to modify the Treatment Guidelines as necessary. Care Managers use Treatment Guidelines while considering Members presenting symptoms, clinical history, bio-psychosocial factors, as well as the Member's benefit plan and availability of services. Services authorized reflect the treatment needs and support the Member's recovery and goals. PBHCS also consults with experts in the field to determine whether health care services are Medically Necessary. The decision to apply expert provider recommendations, the selection of expert and the determination of when to use any such expert opinion, shall be within PBHCS sole discretion. 11

16 PBHCS does not dictate treatment. Determinations of Medical Necessity support whether the benefit plan will pay for any portion of the cost of the behavioral health service, and so decisions are for payment purposes only. The Member and the Provider/Facility make decisions about the actual treatment the Member will receive. When making determinations about Medical Necessity the information used is provided by the Network Provider/Facility to establish whether services are in accordance with standards of practice, are clinically appropriate, not for convenience, and whether services are cost-effective and provided in the least restrictive environment. Exceptions may be made when the Member's condition has not responded to treatment as anticipated. Exceptions are carefully evaluated, documented, and approved by the Behavioral Health Manager, and Physician Advisor and/or Executive Medical Director. It is also expected that an effort will be made to work with the Provider to identify an appropriate level of care and forms of treatment that are most likely to be effective. Clinical guidelines apply to each facility based level of care and specialized services. A. Clinical Assessment and Treatment Planning Optimal treatment is attained when delivered in the setting that is both the least restrictive and the one with the greatest potential for a favorable outcome; a thorough clinical assessment is essential to treatment planning and must include: 1. The mental status exam including an evaluation of suicidal or homicidal risk; 2. A substance use screening, noting any past and present substances abused and treatment interventions; 3. A bio-psychosocial history including previous medical and behavioral health conditions, interventions, outcomes, and current and previous medical and behavioral health providers; 4. Developmental history; 5. Unique cultural and spiritual needs of the Member; 6. Education; 7. Legal issues; 8. Social support; 9. The reason the Member is seeking treatment at the requested level of care at this time; 10. Service options to meet the Member's immediate needs and preferences; and 11. The Member's broader recovery, resiliency and wellbeing goals. The assessment helps to identify symptoms, conditions and co-morbidities that may be important to address in a comprehensive treatment plan based on the Member's presenting condition, and is used to document realistic and measurable treatment goals as well as the evidence-based treatments that will be used to achieve the goals of treatment. Effective treatment planning should take into account significant variables such as age and level of development, the history of treatment, whether the proposed services are covered in the Member's benefit plan and are available in the community. The Provider should also take into account the Member's preferences as might be directly expressed or documented in an advance directive or crisis plan. For some Members, treatment is part of a broader recovery and resiliency effort, so the recovery and resiliency goals which may be documented in a recovery plan should also be considered. B. Reassessment A change in the Member's condition should prompt a reassessment of the treatment plan and selection of level of care. The reassessment should determine whether the condition has improved, and if a less restrictive level of care may be adequate to continue treatment or whether treatment is no longer required. 12

17 When a Member's condition has not improved or it has worsened, the reassessment should determine whether the diagnosis is accurate, the treatment plan should be modified, or the condition should be treated at a different level of care. C. Discharge Planning and Coordination of Care Discharge planning begins at the onset of treatment when the Provider anticipates the discharge date and forms an initial impression of the Member's post-discharge needs. In-Network Providers and Facilities are required to pursue coordination of care with the Member's treating medical or behavioral health clinicians. A signed release of information must be obtained and in the event that a Member declines consent to the release of information, the refusal and the reason should be documented, as well as the information provided regarding the benefits of coordinated care, and the risks thereof. Effective discharge planning enables the Member's safe and timely transition to the subsequent level of care, and documents the services the Member will receive after discharge. The initial discharge plan may evolve in response to changes in the Member's condition. The final discharge plan should document: - discharge date; - services recommendations post-discharge; - care coordination with the Provider at the next level of care; - plan to reduce the risk of relapse, and - Member commitment to follow up with the discharge plan. A timely first appointment post-discharge lessens the risk of relapse, therefore, when Members transition to the next level of care, their first appointment should be scheduled prior to discharge and based on clinical needs. The first post-discharge appointment following inpatient care should occur no later than seven (7) days from the date of discharge. This timeframe is in accordance with the HEDIS standard for follow-up treatment after discharge from inpatient care. PBHCS assesses the compliance of its Network Facilities in meeting this standard on an annual basis and the compliance of its Members and Outpatient Providers about kept appointments. PBHCS's Care Managers monitoring discharge planning are available to assist with identifying and facilitating access to available treatment services. Coordination of care may improve the quality of care to Members in a number of ways: (1) Allows behavioral health and medical providers to create a comprehensive care plan; (2) Allows a primary care physician to know that his or her patient followed through on a behavioral health referral; (3) Minimizes potential adverse medication interactions for Members who are being treated with psychotropic and non-psychotropic medication; (4) Allows for better management of treatment and follow-up for Members with coexisting behavioral and medical disorders; (5) Promotes a safe and effective transition from one level of care to another; and (6) Reduces the risk of relapse. V. UTILIZATION REVIEW PROCESS Utilization Review is a program designed to help ensure that all Members receive necessary and appropriate behavioral health care while avoiding unnecessary expenses. The process is used to monitor utilization and quality of services a patient is receiving throughout the continuum of care. 13

18 The customized InterQual Criteria implemented by PBHCS are updated annually by McKesson Behavioral Health Solutions and are used to aid Level of Care determination when conducting facility based level of care reviews. A. Preauthorization Facilities obtain Preauthorization on behalf of the Member upon admission. In order to obtain Preauthorization a facility representative has to present clinical information to support Medical Necessity, including: - Diagnosis (current DSM or ICD) - Reason for admission/precipitant, question 'why now' - Suicidal/homicidal risk, ideation, plan, intent, presence of Psychotic symptoms - Substance use history including type, amount, withdrawal symptoms, vital signs, date(s) of initial use and last use, date(s) of periods of sobriety - Other presenting problem/symptomatology description, if applicable - Medical problems - Current medications types(s), dosage(s), date(s), duration, response, provider(s) - Other behavioral health care provider, if applicable - General level of functioning including sleep, appetite, mental status, Activities of Daily Living (ADLs) - Psychological stressors and supports, socioeconomic, family, legal, social, abuse, neglect, domestic violence (as appropriate), - Response to previous treatment, previous treatment history, most recent treatment, past treatment failures, relapse/recidivism, motivation for treatment, indications of compliance with treatment recommendations - Treatment plan, estimated length of stay, treatment goals, specific planned interventions, family involvement, precautions for specific risk behaviors, educational component for regulatory compliance and substance use disorder situations - Anticipated Discharge plan, aftercare required upon discharge, barriers to discharge B. Concurrent Reviews A concurrent review is intended to help ensure ongoing treatment authorization based on Medical Necessity at specific time intervals by monitoring a patient's progress since admission to the items listed above. C. Retrospective Reviews A retrospective review occurs when an initial request for authorization or Preauthorization is made after services have already been delivered but no claim has been filed. Retrospective review requests must be submitted within 180 calendar days following the date(s) of service unless otherwise mandated by applicable law. Requests for retrospective review must include information regarding the reason or circumstances preventing required Preauthorization and will be processed at PBHCS's sole discretion. For all retrospective reviews, PBHCS will issue a determination within 30 calendar days of receipt of the request, unless otherwise required by applicable law. Any retrospective review requests received outside the established time frame may not be processed by PBHCS. D. Verbal Preauthorization 14

19 This review concerns documenting the date and time Preauthorization occurred, as well as the Care Manager who spoke directly with the practitioner. This is usually provided to Facilities at the time of a concurrent review for Non-routine MH/SA facility based Levels of Care. E. Written Notice of Authorization of Coverage Determination This written notice is a confirmation of coverage based upon Medical Necessity. The approval letter normally includes (1) the specific clinical rationale for the determination, (2) a description of the Member's presenting symptoms or condition, diagnosis, and treatment interventions, (3) a reference number, (4) the appropriate dates, and (5) the number of days/units of services authorized for pre-service claims or concurrent service claims. F. Written Notice of Denial of Coverage Determination This written notice is a denial of coverage based upon Medical Necessity. The denial letter normally includes (1) the specific clinical rationale for the determination, (2) a description of the Member's presenting symptoms or condition, diagnosis, and treatment interventions, (3) alternative treatment options/services covered under the Member's plan, if any, and (4) a description of the Member's appeal rights and how to initiate an appeal. G. Written Notice of Denial of Payment This written notice outlines the reasons for payment denial and the instructions on how to initiate a provider appeal. VI. NON-COVERED SERVICES Non-Covered Services not deemed Medically Necessary for the diagnosis, treatment of illness trauma, or restoration of mental health/substance abuse impaired functions. Exclusions do not apply to covered preventive services or testing service other than specifically defined as reasons for non-authorization by PBHCS. Non-covered services include, but are not limited to: 1. Services performed in connection with conditions that do not fit current DSM V criteria; 2. Services that are not in connection with a behavioral disorder, psychological injury, or substance abuse; 3. Services that are not consistent with prevailing national standards of clinical treatment of such conditions, including but not limited to PBHCS standards; 4. Services that are not consistent with prevailing professional research demonstrating measurable and beneficial outcomes; 5. Services that demonstrate less effectiveness than less intense or costly treatment alternatives; 6. Services that typically do not result in outcomes demonstrably better than other available treatment alternatives that are less intensive or more cost effective; 7. Treatment that is Experimental or Investigative in nature, including testing or developmental, educational, vocational, occupational, mental capacity or candidacy for specific type or dosage of psychotropic medication or medical/surgical procedures; 8. Treatment of personality disorders where that is the primary diagnosis; 9. Treatment/services related to personal or professional growth/development, educational or professional training or certification, or treatment services required for Investigtive purposes related to employment; 10. Psychoanalysis; 11. Treatment incurred after the date of termination of the Covered Person's coverage or prior to eligibility or enrollment in the plan; 12. Services for which a Covered Person would have no legal obligation to pay; 13. Treatment for any charges that exceed PBHCS's reasonable and customary rates for Out-of- Network care; 15

20 14. Additional treatment necessitated by lack of Covered Person's cooperation or failure to follow a prescribed plan of treatment; 15. Treatment, except for initial diagnosis, of selected DSM V behavioral problems: (a) cognitive rehabilitation, (b) hyperkinetic syndromes, (c) learning disabilities, (d) mental retardation treatment that extends beyond traditional mental health and psychiatric treatment or for environmental or social change, (e) special education including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired; 16. BEAM testing and neuropsychological testing when used for the diagnosis of Attention- Deficit/Hyperactivity Disorder; 17. Services not performed by a Provider; 18. Career and financial counseling; 19. Services or treatment rendered by unlicensed providers, including pastoral counselors, as recognized by the state and federal licensing laws (except as required by law), or which are outside the scope of the providers' licensure; 20. V-Codes; 21. Prescription and non-prescription drugs; 22. Forms of alternative treatment as defined by the Office of Alternative Medicine of National Institutes of Health; 23. Herbal medicine, Holistic or Homeopathic care, Aromatherapy, Ayurvedic medicine, Guided Imagery, Massage therapy, Naturopathy, Relaxation therapy, Transcendental meditation and Yoga; 24. Sedative action electro stimulation therapy; 25. Sensitivity training; 26. Twelve step model programs as sole therapy for eating disorder and addictive gambling; 27. Psychological and/or neuropsychological or neuropsychiatric testing for (a) Learning Disabilities/problems, (b) school related issues, (c) the purposes of obtaining or maintaining employment;(d) the purpose of submitting a disability application for a mental or emotional condition; 28. Recreational, educational, and sleep therapy, including any related diagnostic testing; 29. Research studies; 30. Medical reports, including those not directly related to the Covered Person's treatment, such as employment, camp, education, travel, sports or insurance physicals and reports prepared in connection with litigation except as required by law; 31. Services for which the cost is later recovered through legal action, compromise, or claim settlement; 32. Biofeedback; 33. Charges made only because there is health coverage; 34. Completion of insurance forms; 35. Services provided by a Member of the participant's immediate family by birth or marriage, including spouse, brother, sister, parent or child. This includes services the provider may perform for him or herself; 36. Services provided by someone with the same legal residence as the Member, or who is currently or has at some point resided with the Member; 37. Treatment/services, including motivational training programs, related to personal or professional growth/development, educational or professional training or certification, or for investigative purposes related to employment; 38. Therapy or rehabilitation services including but not limited to (a) primal therapy, (b) chelation therapy (d) Rolfing, (e) psychodrama (f) megavitamin therapy,(g) purging, (h) bioenergetic therapy, (i) vision perception training, (j) cognitive rehabilitative therapy, (k) carbon dioxide therapy, (l) confrontation therapy, (m) crystal healing therapy, (n)cult deprogramming, (o) electrical aversion therapy for alcoholism, (p) narcotherapy, (q) orthomolecular therapy, (r) 16